Resident Fatigue, Distress Can Lead to Medical Errors, Says Study

A Mayo Clinic study published recently in the Journal of the American Medical Association, or JAMA, says that residents who experienced high levels of either fatigue or distress -- or both -- were more likely to report a medical error. The study reinforces the importance of managing residents' sleep needs and maintaining their feelings of well-being to minimize fatigue and maximize patient safety, according to AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, who also is program director and CEO of Family Medicine Residency of Idaho.

It is the responsibility of program directors to help trainees manage their sleep needs and general well-being, said Epperly. "We do that constantly here. We work with residents to help them manage their sleep, fatigue and their distress."

The study, which was published in the Sept. 23/30 issue of JAMA, used data from 380 internal medicine residents who began their training between 2003 and 2008 and completed quarterly surveys through February 2009.

Residents were surveyed about their demographic characteristics, current rotations, coping strategies for dealing with stress and report of self-perceived medical errors. Validated survey tools were used to measure fatigue, quality-of-life, burnout and symptoms of depression.

Previous studies, including a 2006 JAMA article by many of the same authors as the current study, indicate that burnout -- which the authors characterized as one form of distress -- during the physician training process can lead to medical errors. Other studies have suggested that resident fatigue also increases the risk of medical errors.

The current study concluded that high levels of fatigue and distress are separately associated with medical errors, although how much each factor contributes individually to such errors remains unclear.

"While changes have been made to reduce fatigue and sleepiness during residency training, other changes may be necessary to more specifically address distress and burnout," said Tait Shanafelt, M.D., a physician at the Mayo Clinic in Rochester, Minn., and lead author of the study report, in a Sept. 22 press release.

Epperly said he agrees that distress is an important issue among residents, and he added two more: substance abuse and mental or physical illness. But he stressed that these issues are most appropriately addressed locally by program directors.

"With the H1N1 flu epidemic, how do you ensure that residents aren't coming to work sick or with depression? These are all issues of importance," he told AAFP News Now.

The newly released study comes after the Institute of Medicine, or IOM, issued a report in December 2008 that recommended more restrictions on residents' duty hours in an effort to minimize fatigue and maximize patient safety. For example, the IOM recommendations included a stipulation that on-site duty periods not exceed 16 hours unless a five-hour uninterrupted sleep period is provided between 10 p.m. and 8 a.m.

The Academy and other family medicine groups disagreed with the IOM recommendations in a Feb. 3 letter to the Accreditation Council for Graduate Medical Education, or ACGME. The Academy said that the recommendations, if implemented, would hurt patient care while increasing medical training costs.

In June, Epperly hammered that message home again, recommending in testimony during the ACGME National Congress on Duty Hours and the Learning Environment that the ACGME commission research studies to examine whether additional restrictions on resident duty hours would lead to improved clinical outcomes.

The AMA Council on Medical Education also is expected to report on the issue of resident duty hours (pp. 22-41 of 117-page PDF; About PDFs) at the 2009 interim meeting of the AMA House of Delegates in November.

Epperly reiterated that more research needs to be done on resident fatigue and distress and their relationship to patient care and medical errors, but he emphasized that it's important that program directors, who are best suited to deal with residents who may experience these problems, remain in charge of handling these issues at the local level.

"Guidelines can be set nationally, but they should be implemented locally. It's critical that program directors take ownership of these issues," Epperly said.